Palliative certificate/CME vs. formal fellowship training

[visceral0775]

Hello, I plan on doing a formal HPM fellowship at the end of residency. A few EM attendings I work with have also expressed an interest in becoming HPM trained but plan on doing CME credits, getting a certificate, etc in lieu of the fellowship. I suppose with CME credits, etc. you could definitely incorporate that training into your daily clinical practice (EM or whatever field you are in) but I'm just not sure you would be marketable as a full-time HPM doc.

Can anyone comment on doing one vs. the other? Can you get a full-time job without a formal fellowship?

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[Frazier]

Maybe once upon a time, but to land any HPM job worth having -- especially palliative -- you are going to need the fellowship (especially coming from the ED).

There is some discrimination against EM to begin with, applying with CME(?) or a certificate as your palliative training does both the field and your patients a rather large disservice.

Tell them to bite the bullet. If they want to go forth and be a subspecialist, do actual subspecialty training.

CME/certificate is great for primary palliative (implementing into your main specialty the basics)... but to pretend that some CME's are going to make you an expert in this field is, at best, innocently misinformed and, at worst, simply lazy and just "looking for an out" without being willing to do the inconvenience of a fellowship. They will be clinically dangerous.

This is not a field for folks just "looking for an out"... the patients, families, and consulting services deserve more.

PS: I'm glad to see you chose fellowship. After that experience you will see how inadequate "CME" would be for what you actually do.

 

[visceral0775]

Maybe once upon a time, but to land any HPM job worth having -- especially palliative -- you are going to need the fellowship (especially coming from the ED).

There is some discrimination against EM to begin with, applying with CME(?) or a certificate as your palliative training does both the field and your patients a rather large disservice.

Tell them to bite the bullet. If they want to go forth and be a subspecialist, do actual subspecialty training.

CME/certificate is great for primary palliative (implementing into your main specialty the basics)... but to pretend that some CME's are going to make you an expert in this field is, at best, innocently misinformed and, at worst, simply lazy and just "looking for an out" without being willing to do the inconvenience of a fellowship. They will be clinically dangerous.

This is not a field for folks just "looking for an out"... the patients, families, and consulting services deserve more.

PS: I'm glad to see you chose fellowship. After that experience you will see how inadequate "CME" would be for what you actually do.

Thank you

I am in agreement with everything you've said. I couldn't imagine doing HPM without a formal fellowship for all the reasons you mentioned. I was just curious since I have heard at least a few say that they plan on doing it without a fellowship and wanted to know if there was something I was missing lol. Unfortunately I don't think there's as much of an appreciation for this field by many EM folks. I am slowly getting used to the funny looks I get when I say I want to pursue this field (although there have been some that are receptive).

 

[Frazier]

Thank you

I am in agreement with everything you've said. I couldn't imagine doing HPM without a formal fellowship for all the reasons you mentioned. I was just curious since I have heard at least a few say that they plan on doing it without a fellowship and wanted to know if there was something I was missing lol. Unfortunately I don't think there's as much of an appreciation for this field by many EM folks. I am slowly getting used to the funny looks I get when I say I want to pursue this field (although there have been some that are receptive).

You're in good company!
Many EM attendings were completely confused at my shop when I shared my plans!

The same rule applies as the old argument: "docs have 10x the training of APP's, so why do APP's think they can do exactly what docs do?"

There was about 3,000 hours dedicated to learning HPM this year in fellowship (between clinical duties and studying)...and I still recognize there is WAYS to go, so much more to learn, improve, and maybe one day master...

But you (general you) think you should be held equivalent as an HPM specialist , work as a palliative doc, with just 20 hours of CME to your name?

It is rather preposterous and the classic Dunning Kruger mixed with "you don't know what you don't know".

Note: in the past fellowships didn't exist or were a brand new idea... it was a different time and people got into hospice/palliative via different means, I understand that and with their now years and years of practice, many are represented on modern faculty... But for the new person entering today, different story, the field has evolved -- do the fellowship if you want to subspecialize.

n=1

 

[visceral0775]

You're in good company!
Many EM attendings were completely confused at my shop when I shared my plans!

The same rule applies as the old argument: "docs have 10x the training of APP's, so why do APP's think they can do exactly what docs do?"

There was about 3,000 hours dedicated to learning HPM this year in fellowship (between clinical duties and studying)...and I still recognize there is WAYS to go, so much more to learn, improve, and maybe one day master...

But you (general you) think you should be held equivalent as an HPM specialist , work as a palliative doc, with just 20 hours of CME to your name?

It is rather preposterous and the classic Dunning Kruger mixed with "you don't know what you don't know".

Note: in the past fellowships didn't exist or were a brand new idea... it was a different time and people got into hospice/palliative via different means, I understand that and with their now years and years of practice, many are represented on modern faculty... But for the new person entering today, different story, the field has evolved -- do the fellowship if you want to subspecialize.

n=1

Thank you! Will keep the updates going from my side as I enter into fellowship application season soon

 

[visceral0775]

Maybe this is a silly question, but to become HPM board certified, does one need to first become board certified in their primary residency training (in my case, EM)?

 

[Frazier]

Maybe this is a silly question, but to become HPM board certified, does one need to first become board certified in their primary residency training (in my case, EM)?

Not silly at all.
As someone who doesnt plan to practice raw EM in the future, I pondered it myself in prior years.

Here is the short answer: you need certification in your primary specialty.

Here is the longer answer:

"The initial certification exam in Hospice and Palliative Medicine for allopathic physicians is adminsitered by the American Board of Internal Medicine. Each cosponsoring board publishes its own eligibility criteria for physicians seeking admission to the HPM certification exam.

You can visit your primary board for specific criteria with the links above.The initial certification exam is offered in the fall every other year (even numbered years).

In general, candidates must

be board certified and in good standing by one of the 10 cosponsoring primary boards
hold a valid, unrestricted, and unchallenged license to practice medicine
demonstrate clinical competence and moral and ethical behavior in a clinical setting, typically with a letter or affidavit from the fellowship program director
have satisfactorily completed a 12-month fellowship in hospice and palliative medicine with an ACGME-accredited HPM fellowship program."

 

[visceral0775]

Not silly at all.
As someone who doesnt plan to practice raw EM in the future, I pondered it myself in prior years.

Here is the short answer: you need certification in your primary specialty.

Here is the longer answer:

"The initial certification exam in Hospice and Palliative Medicine for allopathic physicians is adminsitered by the American Board of Internal Medicine. Each cosponsoring board publishes its own eligibility criteria for physicians seeking admission to the HPM certification exam.

You can visit your primary board for specific criteria with the links above.The initial certification exam is offered in the fall every other year (even numbered years).

In general, candidates must

be board certified and in good standing by one of the 10 cosponsoring primary boards
hold a valid, unrestricted, and unchallenged license to practice medicine
demonstrate clinical competence and moral and ethical behavior in a clinical setting, typically with a letter or affidavit from the fellowship program director
have satisfactorily completed a 12-month fellowship in hospice and palliative medicine with an ACGME-accredited HPM fellowship program."

Thank you

 

[sylvanthus]

You're in good company!
Many EM attendings were completely confused at my shop when I shared my plans!

The same rule applies as the old argument: "docs have 10x the training of APP's, so why do APP's think they can do exactly what docs do?"

There was about 3,000 hours dedicated to learning HPM this year in fellowship (between clinical duties and studying)...and I still recognize there is WAYS to go, so much more to learn, improve, and maybe one day master...

But you (general you) think you should be held equivalent as an HPM specialist , work as a palliative doc, with just 20 hours of CME to your name?

It is rather preposterous and the classic Dunning Kruger mixed with "you don't know what you don't know".

Note: in the past fellowships didn't exist or were a brand new idea... it was a different time and people got into hospice/palliative via different means, I understand that and with their now years and years of practice, many are represented on modern faculty... But for the new person entering today, different story, the field has evolved -- do the fellowship if you want to subspecialize.

n=1

Why not? NPs are doing it in a lot of places already.

 

[Frazier]

Why not? NPs are doing it in a lot of places already.

Well sure, a hospital system can label anything they want as whatever they wish.

I can hire an NP or PA and say okay at this office you now practice Totality Medicine. You are now a Totalologist.
At many hospitals what they describe as "palliative medicine" isn't really the actual breadth of the field -- but rather pure goals of care and/or hospice enrollment.

Case in point: at my residency hospital, the "palliative care service" was this: a single NP that solely met with patients to enroll them in hospice [with the goal from the hospital-side of things to lower mortality rate figures]. I don't think I ever saw her supervising physician in 3 years, I don't know what the doc's training was. Maybe she didn't even have one. That's okay. While the hospital labeled that as the "palliative care service" it was a shell name and might as well just been called Totality Medicine or any other made-up phrase to meet their motive's need.

That said NP/PA do indeed function within the realm of palliative medicine within an IDT structure and offer a welcomed additional layer of support for patients. Our palliative social workers, palliative pharmacists, palliative music therapists, palliative chaplains, palliative nurse navigators, and everyone else all offer their own layer of support too.

It is a pure referral-based subspecialty. Show me a "palliative NP private practice" and I'll show you what is very likely an opioid pill mill running off the grid. As you know, oncologists, surgeons, cardiologists, hematologists, etc make the referrals and are gatekeepers for our patients -- which makes perfect sense. These physicians tend to be protective of their folks and refer to palliative services they know and trust to help in either ongoing concurrent care or taking over care of these patients.

So to your point, the goal shouldn't be to lower the bar for everyone just because some people do things the wrong way.
Here is a NP and Chiro doing a stellate ganglion block... as well as a video of a naturopath doing a stellate ganglion block.

A Nurse Practitioner and a Chiropractor walk into a procedure room and...stellate ganglion block

This nurse practitioner is doing a stellate ganglion block while her chiropractor operates the ultrasound machine. San Diego. This NP lists herself as the "Lead Provider" in the clinic. About Us - Regenerative Medicine | San Diego | Joy Wellness Partners

forums.studentdoctor.net

That doesn't mean the rest of us should skip training and start doing it too.

Do the right thing for the field, yourself, and your patients/families.
Do the fellowship and get the proper training to be a well-training subspecialist physician -- not a person pretending or just faking it until they [maybe] make it.

 

[sylvanthus]

No point getting the training if you cant find a job. Guess you can pat yourself on the back that you are the best trained evaaahhh. However with the massive influx of midlevels in pretty much all fields, you can see what is going to happen to jobs down the road.

 

[Frazier]

It's not about patting oneself on the back at all. I don't think that is a particularly common trait of people that seek out this subspecialty.

It isn't "I'm God's gift to medicine because I did a HPM fellowship", so much as it is "I'm going to give my patients and their families the best care possible."

If you want to practice with the scope of primary palliative care, then no need for a fellowship. Do some trainings. Perhaps it is fulfilling to that physician. But actual subspecialty palliative care would benefit from dedicated longitudinal training. I did EM, I did that training, I know what many of the EM programs are like from some leadership positions back then at the hospital, state, and national level. Essentially none have meaningful HPM education/experiences built into curriculum. Walking out of EM training, one is ill-equipped to practice subspecialty palliative care. And that is okay -- therein lies the purpose of fellowship.

Regarding jobs, there might be less of the fake positions I described above available to burned out docs that just want to coast and make money with minimal effort required. That is okay -- as one doesnt need a fellowship to discuss hospice as a disposition from the hospital (thoughtful practice and effort to do it well however). Social workers often help with that as is. Let our NP and social work colleagues help with those tasks if able, as we work toward putting out the fires for the other patients on our census.

It is a very rewarding field.

 

[visceral0775]

It's not about patting oneself on the back at all. I don't think that is a particularly common trait of people that seek out this subspecialty.

It isn't "I'm God's gift to medicine because I did a HPM fellowship", so much as it is "I'm going to give my patients and their families the best care possible."

If you want to practice with the scope of primary palliative care, then no need for a fellowship. Do some trainings. Perhaps it is fulfilling to that physician. But actual subspecialty palliative care would benefit from dedicated longitudinal training. I did EM, I did that training, I know what many of the EM programs are like from some leadership positions back then at the hospital, state, and national level. Essentially none have meaningful HPM education/experiences built into curriculum. Walking out of EM training, one is ill-equipped to practice subspecialty palliative care. And that is okay -- therein lies the purpose of fellowship.

Regarding jobs, there might be less of the fake positions I described above available to burned out docs that just want to coast and make money with minimal effort required. That is okay -- as one doesnt need a fellowship to discuss hospice as a disposition from the hospital (thoughtful practice and effort to do it well however). Social workers often help with that as is. Let our NP and social work colleagues help with those tasks if able, as we work toward putting out the fires for the other patients on our census.

It is a very rewarding field.

"I know what many of the EM programs are like from some leadership positions back then at the hospital, state, and national level. Essentially none have meaningful HPM education/experiences built into curriculum. Walking out of EM training, one is ill-equipped to practice subspecialty palliative care. And that is okay -- therein lies the purpose of fellowship."

This is true of my institution as well. It does surprise me that as an EM resident, we get absolutely zero training in HPM, especially given how many chronically ill patients we care for as well as the cardiac arrests, traumas, strokes and other acute patients who end up requiring life support.